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Mindful EM: Teaching is as Easy as SMART NERDS

Hazan, Alberto MD; Haber, Jordana MD

doi: 10.1097/01.EEM.0000526102.64190.2c
Mindful EM

Dr. Hazan is an emergency physician and the regional medical director of DMS-Envision in Las Vegas. He is the author of the medical thriller Dr. Vigilante and the urban fantasy series The League of Freaks. Find out more about his novels at He is also a board member with Follow him on Twitter @Dr_Vigilante. Dr. Haber is an emergency physician and the director of clinical education at University Medical Center in Las Vegas. She has a master's degree in medical education. Follow her on Twitter @JoJoHaber. Read their past articles at





Our number one priority is to care for our patients—to resuscitate and rule out life-threatening emergencies. It is also important, however, for us to educate our patients and team, especially our new providers with regular and effective feedback on their clinical skills so our ED teams are the best they can be.

We should foster teaching as an aspect of our practice, just as we hone our clinical skills. We received years of training to care competently for patients but little to no training on how best to teach. It's no wonder that it's easier for us to lead a resuscitation than to teach one.

Regular feedback from preceptors is especially pertinent to new practitioners, who commonly don't know what it is they don't know. Research has shown that learners who receive regular feedback about their performance function significantly better, develop better judgment and skills of self-assessment, and learn faster than those who don't.

Providing effective feedback is also an essential method to communicate our expectations and an important way to let our team know that we are approachable, will listen to them if they have concerns, will keep them informed, and are invested in their learning and growth.

All feedback is not the same, however. The SMART feedback model, which we adapted from the SMART goal-setting model, provides feedback that is Specific and clear to the learner's needs, Measurable to track progress, Attainable and Relevant to the learner, and provided at the right Time. (Management Review 1981;70[11]:35.) Common times to give feedback are during a patient presentation, when debriefing on a patient encounter, and when teaching procedural skills.

Feedback should also be based on an assessment of the learner or trainee with whom we are working. This requires us to have tools to identify the learner's level and create a plan to meet his needs, similar to how we gather information on our patients before creating an assessment and plan.

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Know Thyself

Often our trainees are able to self-assess and tell us where they want feedback. We should encourage this by helping them develop self-assessment skills so they can guide their own growth.

The RIME model helps identify the skill level of a learner. (Med Educ 2008;42[12]:1205; Practical Guide to the Evaluation of Clinical Competence: Philadelphia: Mosby; 2008.) At the Reporter level, we should expect the learner to be able to collect data accurately. They then move to the Interpreter level when they're able to convey what they think is going on. At the Manager level, the learner articulates a supported plan based on their assessment. At the Expert level, they can manage more complex cases and situations, and practice independently. Using this model, feedback can be provided to the learner about where he is and what he needs to get to the next level.

Effective feedback need not be time-consuming. In fact, teaching effectively and providing SMART feedback will only take a few minutes, which is perfect for our busy ED shifts. The One Minute Preceptor model of clinical teaching summarizes the five important tasks of microteaching. (J Am Board Fam Pract 1992;5[4]:419.) The mnemonic NERDS, developed by Gabe Sudario, MD, summarizes the five fundamental microskills. (

N stands for nickel down, which refers to the commitment required from the learner. The goal is to get your learner to commit to an aspect of the case just beyond his level of comfort. You can ask novice learners (or learners at the reporter level) what they think is going on with their patient, which will guide them to the interpreter level. The commitment for more advanced learners at the interpreter or manager level might be centered around treatment, diagnostic workup and tests, and follow-up plans. E stands for evidence. Here, you ask learners what factors they considered in making their diagnosis, assessing their knowledge and clinical reasoning. How did they connect a clinical presentation to what they know? This information identifies gaps in their knowledge and application.

R stands for rules. From any medical case with which you are presented, you want to find the general rules or teaching points that can be applied to similar cases. D stands for do. Provide positive feedback on what was done properly in the form of SMART feedback, focused on specific behaviors and decisions that were done right to reinforce competence and foster engagement and motivation. S stands for stop; correct mistakes or behaviors that shouldn't occur again and provide feedback on how to do something better or differently. This should be informative and constructive, targeted at correcting a specific behavior for future practice. It is appropriate to provide this feedback in a private setting.

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